Waqas M et al, 2017: Comparison of Different Analgesia Drug Regimens for Pain Control During Extracorporeal Shock Wave Lithotripsy for Renal Stones: A Randomized Control Study.
Waqas M, Butt A, Ayaz Khan M, Khan I, Saqib IU, Hussain T, Akhter S.
Department of Urology, Shifa International Hospital, Islamabad, Pakistan.
Department of Urology, Pakistan Kidney Institute, Islamabad, Pakistan.
Department of Plastic Surgery, Shifa International Hospital, Islamabad, Pakistan.
Lithotripsy Department, Shifa International Hospital, Islamabad, Pakistan.
INTRODUCTION: With the increased use of extracorporeal shock wave lithotripsy (ESWL), the management of urolithiasis has become much convenient for the patients and the health care professionals alike. However, associated with the procedure is the common complaint of pain. No agreed upon pain management strategy has yet been developed for the procedure. We compared the effect of different analgesia drug regiments for pain control.
METHODOLOGY: A randomised controlled trial was carried out in Shifa International Hospital from between July 2015 to January 2016. A total of 135 patients were divided into three groups; group A received 30 g lidocaine 2% gel applied locally on corresponding lumber area 30 minutes before the procedure, group B received oral naproxen sodium 550 mg 45 minutes before the procedure, and group C received both oral naproxen and lidocaine gel. Patients were supplemented with intravenous nalbuphine during the procedure. The pain was assessed with 0-10 visual analogue scale. Both pre-procedure and post-procedure pain score was measured.
RESULTS: Among 135 patients, 105 (77.8%) were male and 29 (21.5%) were female with mean age of 38.7 ± 1.31 years. There was no difference of mean pain score or need for supplemental intravenous nalbuphine between groups B and C but there was significantly decreased mean pain score and need for supplemental intravenous nalbuphine in groups B and C in comparison with group A.
CONCLUSION: The use of oral naproxen sodium with or without the addition of lidocaine gel during ESWL is a promising option for pain management during the procedure with significant improvement in comparison with lidocaine gel alone.
Cureus. 2017 Apr 26;9(4):e1195. doi: 10.7759/cureus.1195. FREE ARTICLE
It is correctly concluded by the authors that poor analgesia results in poor patient compliance and insufficient treatment results. The authors, moreover, confirm early results with topical application of EMLA-cream  during treatment with the unmodified Dornier HM3 lithotripter without regional or general anaesthesia. It was observed in that study that EMLA had some limited effect when the shockwave power was low. When the energy was increased the visceral pain dominated. The lack of effect of topical analgesics used with modern lithotripters also showed that the pain at body entrance (skin level) represents only a small part of the total pain experience.
Although there are no guidelines on how analgesia should be carried out during SWL, my personal experience is - after application of several different regimens over the years - that the winning concept is intermittent administration of small doses of alfentanyl and propofol. This method has successfully been applied in more than 10 000 SWL-treatments in Stockholm. The mean doses during one session (based on data from 3 500 treatments) were ~ 0.9 mg of alfentanyl and ~74 mg of propofol.
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